Chapter 46

Basal cell carcinoma (BCC) is the most common Ca in the world. Caused by UV
radiation exposure and is also associated with arsenic in food or water, radiation
therapy, and long-term immunosuppressive therapy. It arises from mutation in the
TP53 tumor-suppressor gene, leading to loss of keratinocyte repair functions and
apoptosis resistance of DNA-damaged cells.
Psoriasis treatment is individualized and r/t maintaining skin moisture, reducing
epidermal cell turnover and pruritus, promoting immunomodulation, preventing and
managing comorbidities, and assuring support systems to maintain quality of life.
Mild psoriasis is treated with topical corticosteroids, vit D analogues, emollients,
keratolytic agents and ultraviolet light therapy. Systemic therapy is indicated for
moderate to severe disease or with the presence of psoriatic arthritis. Txmt includes
methotrexate, acitretin, cyclosporine and biologics that target TNF-alpha, IL-17, and
IL-23.
Allergic Contact Dermatitis (ACD): A common form of T-cell-mediated or delayed
hypersensitivity. The response is a consequence of alterations in skin barrier
function. Genetic susceptibility involves several genes, including loss of function
mutations in the gene encoding the epidermal protein filaggrin. When an allergen
contacts the skin, it is bound to a carrier protein, forming the sensitizing antigen.
S/S, Pathophysiology, Source of infection and definition
- Impetigo: Superficial skin infection that’s caused by coagulase-positive Staph
of beta hemolytic strept. Occurs in adults but more common in kids.
- Tinea: Transmitted via direct contact with the causative organisms, through
person to person contact or via non-living objects. Diagnosed by culture.
The third layer of the skin is subq tissue (hypodermis) and consists of adipose tissue.
The lobules are separated by fibrous walls (septa) of collagen and large blood
vessels. Dermal collagen is continuous with the collagen found in Subq tissue.
Eccrine sweat glands are distributed over the body with the greatest numbers in the
palms of hands, soles of feet and forehead. They are important for thermoregulation
and cooling of the body through evaporation.
Pressure ulcers vary based on staging. Stage 1 consists of non-blanchable erythema
of intact skin usually over a bony prominence. Darkly pigmented skin may appear
differently. Color changes don’t include purple or maroon discoloration. Stage 2 is a
partial thickness skin loss with exposed dermis involving epidermis or dermis
presenting as a shallow open ulcer with a red-pink. Deeper tissues are not visible.
Stage 3 is a full thickness skin loss involving damage or necrosis of subcutaneous
tissue that may not extend to underlying fascia. Adipose tissue visible in the ulcer,
Stage 4 is full thickness skin and tissue loss with exposure of muscle, bone or
supporting structures. Can include undermining and tunneling.
A keloid is an irregularly shaped, elevated, progressively enlarging scar. Grows
beyond the boundaries of the wound. It’s caused by excessive collagen formation
during healing. Ex: Keloid formation after surgery. Keloids are fibrous lesions and
often characterized by pruritus, pain and psychological discomfort. They are likely to
recur after surgical removal and treatment is often ineffective.
Types of psoriasis
- Plaque psoriasis is most common. The typical plaque psoriatic lesion is a
well-demarcated, thick, silvery, scaly, erythematous plaque surrounded by
normal skin. Small, erythematous papules enlarge and coalesce into larger
inflammatory lesions.
- Inverse psoriasis is rare and involves lesions that develop in skin folds. They
are large, smooth, dry and deep red.
- Guttate psoriasis manifests as small papules that appear suddenly on the
trunk and extremities a few weeks after a streptococcal respiratory tract
infection. May resolve spontaneously in weeks or months.
- Pustular psoriasis appears as blisters of noninfectious pus (collections of
neutrophils) that develop over areas of plaque psoriasis.
- Erythrodermic (exfoliative) psoriasis is characterized by widespread red,
scaling lesions that cover a large body surface area (BSA) and is often
accompanied by pruritus or pain associated with symptoms (fever, chills,
fatigue) and skin infections.
- Psoriatic arthritis (PA): Associated with proinflammatory cytokines that cause
psoriatic skin lesions. Arthritis of major joints, enthesitis, dactylitis and nail
disease.
- Psoriatic nail disease can occur in all psoriasis subtypes with pitting,
onycholysis, subungual hyperkeratosis, and nail plate dystrophy.
Scleroderma is a connective tissue disease associated with immune dysregulation,
vascular alterations, and progressive fibrosis. Localized scleroderma or morphea is
usually more benign and self-limiting and is confined to the skin and/or underlying
tissues. Systemic sclerosis is characterized by cutaneous sclerosis with organ
involvement.
During rewarming after frostbite, there is indirect injury r/t progressive
microvascular thrombosis followed by reperfusion injury with the release of
inflammatory mediators (thromboxanes, prostaglandins, bradykinins and histamines)
with impaired circulation and anoxia to the exposed area. Cyanosis and mottling
develop, followed by redness, edema, and burning pain on rewarming in more severe
cases. Ibuprofen can be used to treat pain and for anti-inflammatory purposes.
Atopic dermatitis: Common in individuals with a history or family history of atopy
eczema, asthma, and/or allergic rhinitis. Associated with IgE antibodies. More
common in infancy and childhood. Genetic predisposition. Filaggrin gene mutations a
filaggrin deficiency. S/S include severe pruritus and eczematoid appearance with
redness, edema, and scaling. Skin is dry and easily irritated. Itching is hallmarking
and rubbing/scratching to relieve the itch. In young kids, Rashes appear on the face,
scalp, trunk and extensor surfaces of arms and legs. In older kids/adults, rashes are
found on the neck, antecubital and popliteal fossae and hands and feet. No specific
lab features.
Latex allergy can be a type IV delayed hypersensitivity reaction to chemicals used in
latex rubber processing or a type I immediate hypersensitivity reaction with IgE
antibodies formed in response to latex rubber protein.
Mycosis fungoides can present as focal or widespread erythematous patches or
plaques, follicular papules, comedone-like lesions and tumors. Most prominent
subtype of cutaneous T cell lymphomas. Lesions are pruritic and cause considerable
distress and debilitation.
Hypersensitivity to an allergen triggers anaphylaxis. Altered immunologic response
to an antigen that results in disease or damage to the individual. Mast cells release
histamine and play a role in hypersensitivity reactions in the skin. Macrophages are
phagocytic and participate in immune responses.
Langerhans cells (type of dendritic cell) and dermal dendritic cells initiate an immune
response by presenting processed antigen to T cells, thus providing a defense against
environmental allergens.
Only mast cells release histamine and play a role in hypersensitivity reactions in the
skin.
Only fibroblasts secrete the connective tissue matrix and collagen.
The eccrine sweat glands are responsible for thermoregulation of the body.
Heat loss can be regulated by varying blood flow through skin. The SNS regulates
vasoconstriction and vasodilation through alpha adrenergic receptors only.
Nonblanchable erythema of intact skin, over bony prominences usually, is Stage 1.
Superficial pressure ulcers should be covered with flat, non bulky dressings that
cannot wrinkle or cause increased pressure or friction.
Only keloids typically send out clawlike prolongations.
Abnormal wound healing with excessive fibroblast activity and collagen formation
causes keloids.
In allergic contact dermatitis, only Langerhans cells process the antigen and present
them to T cells.
In latex allergies, IgE antibodies are formed in response to latex rubber protein.
Most common inflammatory disorder of the skin is eczema or dermatitis. Pruritus,
lesions with indistinct borders and epidermal changes.
Only erythema and pruritus are exhibited in allergic contact and stasis dermatitis.
Lesions on the elbows and knees that are well demarcated, thick, silvery, scaly and
erythematous characterize plaque psoriasis.
Pityriasis rosea begins with a single lesion known as a herald patch. This lesion is
circular, demarcated, and salmon pink. 3-4 cm and usually on the trunk.
Skin biopsy with immunofluorescent observation reveals lumpy deposits of IgM.
Carbuncle is used to identify a collection of infected hair follicles occurring most
often on the back of the neck, upper back and lateral thighs, Lesion begins as a firm
mass and evolves into painful, swollen mass and drains through many openings.
Chicken pox (varicella) may be followed by herpes zoster (shingles) years later.
Tinea corporis is a fungal infection of the skin.
Cutaneous vasculitis involves deposit of immune complexes and causing lesions that
are polymorphic.
Urticaria is mediated by the IgE stimulated release of histamine, bradykinin or
kallikrein from mast cells or basophils.
Scleroderma is associated with immune dysregulation and several autoantibodies.
Seborrheic keratosis is a benign proliferation of cutaneous basal cells that produces
smooth or warty elevated lesions. Chest, back and face varying from tan to waxy
yellow, flesh-colored, or dark brown to black.
Basal cell carcinoma has depressed centers with rolled borders on face and back.
Basal cell carcinoma arises as a consequence of UVL mutation in TP53.
Bowen disease is a form of squamous cell carcinoma.
Only the intradermal nevus is characterized by a small lesion with regular edges and
bristle-like hairs with color changes.
The endothelial cell is thought to be the progenitor of Kaposi sarcoma.
Immersion in warm bathwater until frozen tissue is thawed is the best treatment for
frostbite.
Ibuprofen is used to inhibit prostaglandins.
Onychomycosis is the term used to identify a fungal or dermatophyte infection of
nail plate.
A furuncle or boil is an inflammation of the hair follicles (root).
Decreased cell proliferation, decreased blood supply, and decreased immune
responses delay wound healing in aging skin.
A nevus, or mole, is a benign pigmented or nonpigmented lesion that forms from an
aggregation of melanocytes. Cells move down into the dermis and the nevi become
nodular and symmetrical w/o irregular borders. Nevi may undergo transition to
malignant melanomas. Nevi repeatedly traumatized, irritated by clothing or large
lesions can be excised.
Kaposi sarcoma is a vascular malignancy. It’s associated with drug induced
immunosuppression, Its endemic form has been found in equatorial Africa, The
classic form appears on the lower legs of older men, It is associated with AIDS.
Antimalarial drugs, lithium, NSAIDS, and beta blockers tend to exacerbate existing
psoriasis.
The inflammatory mediators of frostbite include prostaglandins, thromboxanes,
bradykinin and histamine.
Women who develop hirsutism may be secreting hormones associated with ovarian or
adrenal disease. Should be evaluated for PCOS, Adrenal hyperplasia, or adrenal
tumors.
Urticaria, allergic reaction, exhibits elevated, irregular-shaped areas of cutaneous
edema. Lesions are solid and transient with a variable diameter.
Varicella, Herpes zoster are elevated circumscribed, superficial lesions filled with
serous fluid and measure less than 1 cm in diameter.
Wart (verruca) or lichen planus are elevated, firm, circumscribed areas less than 1
cm.
Psoriasis or seborrheic and actinic keratoses are elevated, firm, and rough lesions
with flat-top surfaces that measure >1 cm in diameter.
Nevus: Flat, circumscribed area less than 1 cm in diameter.